Diabetic foot disease: HuffPo hasn't a leg to stand on

As an internist, my specialty is the prevention and treatment of adult diseases. One of the most common of these diseases is diabetes.

There are two main variants of diabetes: Type I (juvenile) and Type II. Type II accounts for about 95% of the 20 million cases of diabetes in the U.S. Diabetes is can be a disabling and deadly disease, but not because of the blood sugar fluctuations per se. High blood sugar damages blood vessels, which in turn damages the organs they supply.

Prevention of these complications has been the goal of diabetic treatment for years. Large-scale studies of type I and type II diabetics have shown that better control of blood sugar levels (to an extent: data indicate that being too aggressive can increase mortality) reduces the incidence of microvascular complications) . Control of cholesterol and blood pressure have been shown to prevent macrovascular complications in type II diabet
es. (DCCT and UKPDS)

What does this mean in the day to day life of a diabetic? One of the most devastating complications of diabetes is amputation, which is often due to both the macrovascular and microvascular complication of peripheral neuropathy. This can begin as a tingling, burning pain in the feet, but can lead to loss of sensation. Small injuries can rapidly become limb-threatening. (Warning: Yucky picture under the fold)

In 2002, over 80,000 amputations were done on diabetics. Evidence suggests that we have the ability to prevent one-half to two-thirds of amputations. Prevention includes yearly foot exams by a medical professional, including simple tests of sensation and blood flow. Evidence supports that prompt referral to a podiatrist for specialized foot care and cessation of all smoking can help prevent amputation.

I recommend that all my diabetics check their feet daily, with a mirror if necessary, and call me promptly with any problems. I examine their feet every three months, and encourage them to follow up with a podiatrist.

So that’s that. Sort of.

Diabetic peripheral neuropathy (DPN) is often a precursor to foot ulceration and amputation. The evidence supports control of blood sugar as the primary way to prevent neuropathy, and the above interventions to prevent complications. There are a number of drugs that can be used to treat the symptoms of DPN, although none is perfect. There is also interest in newer agents, such as alpha-lipoic acid, in the treatment of DPN. But now, one of the health gurus at the Huffington Post is weighing in, and the information is wrong, and probably dangerous.

Robert Kornfeld is a podiatrist. For all I know, he is an excellent podiatrist. But his knowledge about diabetes is incomplete. Like many alternative medicine practitioners, he falsely equates the benefits of behavioral changes with a lack of benefit of medical therapies:

In my opinion, one of the biggest misconceptions in modern medicine is the assumption that diabetes can be controlled by medication alone. The truth is that it simply can’t be. Somehow our culture has developed this fantasy that people can eat anything they want, do no exercise,
and any health complications will be resolved with a few pills or injections. Nothing could be further from the truth.

His opinion is not the same as evidence. “The truth” is that diabetes can, and often is, well-controlled by medicine alone. This isn’t because real doctors prefer it that way; it is because many diabetics cannot adhere to diet and exercise programs, and many diabetics do not have enough pancreatic beta cell function left to avoid medications. Kornfeld’s musings on the limitations of various sorts of laboratory measurements are interesting, but are simply his opinion. We can and must have proxy measurements for diabetic control. Fasting blood glucose and hemoglobin A1C have been studied extensively, and rising measurements directly correlate with the pathologic vascular changes of diabetes. This, and the fact that it is possible to correlate peripheral neuropathy and measurements of glucose control such as HbA1C renders Kornfield’s beliefs moot.

This isn’t to say dietary modification isn’t useful, but to imply that this is the only way to prevent diabetic complications is fallacious. Kornfield goes on to give dietary advice which may or may not be good, but as a professor of mine once said, “there is a reason podiatrists are only licensed to practice below the leg.” His assertion that organic foods are less “toxic” and an important part of a diabetic diet is simply ridiculous.

As the image above should illustrate, diabetes is a serious problem, a threat to life and limb, and people who litter the world with bad advice are as much a part of the problem as a big piece of chocolate cake—but not quite as yummy.

41 Comments

JustaTech

A friend’s mother had her foot amputated due to diabetic ulcers (complicated by bone damage due to chemo years ago). It was very hard for everyone, but it was clearly necessary. It might even help her, in that a prosthetic won’t break like a foot with fragile bones.
My grandmother’s retirement community had a “traveling podiatrist” who came by every month to check everyone’s feet, diabetic or not. They considered it great fun.

the bug guy

In my opinion, one of the biggest misconceptions in modern medicine is the assumption that diabetes can be controlled by medication alone.

That’s something that always frustrates me. When I was first diagnosed with Type II diabetes four years ago, the first thing my PCP did was to send me to a diabetes facility. They thought me how to manage diet to control blood sugar and I have been able to successfully do that ever since. Granted, my diabetes was caught early and is still very mild, but that alt med attitude that medicine ignores non-medication methods still burns me.

Rogue Epidemiologist

White people are the point of reference for risk of developing NIDDM; risk is elevated for all other race groups. Why is that? Why are white people apparently more tolerant of sugar (or at least more capable of insulin sensitivity)?
@JustaTech
We traced an outbreak of acute Hep B among diabetics to a traveling podiatrist. Looks like we need more autoclaves. Or we oughtta recommend Hep B vaccination for group living facilities.

Pat

I absolutely wish we had a pill that could alter people’s behavior. I’d like one that made sugar taste foul to me. But barring that we have medications and treatments, and thank goodness. No alt-med would help Type I diabetics, no matter how much of The Secret they might know, no matter how many tinctures of silver or Reiki treatments they got. Type II, like my father and two of my friends, sometimes can get better if they change their lifestyle (one of them) but some need medications because they can’t change their lifestyle. The homebound, the infirm, those incapable of strenuous exercise…
But then, with the thought-causal relationship that appears to permeate alt-med (I can’t count the times I’ve heard sickness is a state of mind) apparently people want desperately to be sick, and eventually everyone turns suicidal, and it’s always terminal.

Are outcomes just as good for those whose diabetes is controlled by medication alone as for those who include dietary and exercise adjustments? I’m just curious as to what studies you are using to establish that people’s diabetes is as well controlled without diet and exercise (while not at all disputing that some people will not make lifestyle changes). Just curious.
Sharon

PalMD

I’ll have to look at that more closely, Sharon. That’s a tough thing to study, as most studies are flexible. For serious diseases, if a patient isn’t responding well in one group they may be allowed to cross over into another group. Also for things like bp and dm studies, there is often a protocol that allows a ramping up of therapy as needed because to simply watch people get worse is not good.
It may also be that DM that is diet-controlled is a different disease than that which is not, given differing levels of insulin resistance and differing pancreatic beta cell reserve.

Nice article. It is inconceivable that anyone who considers themselves a “real” health care provider would not address things like diet and exercise. It is also irresponsible for any health care provider to suggest that medications are not really necessary. Organic foods are not lower in “toxins” either.
Using arginine as a long term supplement has been shown to not work for peripheral arterial disease. The rationale that people use is that arginine is the substrate for nitric oxide synthase, and when arginine is given acutely NO levels do go up. But taking arginine supplements every day is not taking it acutely. The NO level is too important to be determined by how much arginine there is in the diet. Once you have “enough” (i.e. enough to ward off arginine deficiencies), the NO level is set by other things. One of the things that happens is that there is upregulation of asymmetric dimethyl arginine, which is a very potent inhibitor of nitric oxide synthase.
I think it is unfortunate that the term diabetes is applied to both type 1 and type 2. They really are fundamentally very different disorders, and you can have either one, or both at the same time. In neither of them is blood glucose not well controlled. In type 1, blood glucose does get high, but that is because cells are not taking up glucose because they don’t express enough GLUT transporters. Give them enough insulin and cells take up enough glucose and blood glucose levels go down. The “important” parameter in glucose delivery is not how much is in the blood, but how much gets into cells. The blood is just the body’s mechanism for getting glucose into cells. When the cells get enough, the body turns down the supply in the blood.
In type 2 cells are not getting enough glucose either, but the body is still making insulin and that insulin is effective at causing cells to express GLUT transporters (until they saturate). Blood glucose still gets high because cells are not getting enough glucose and higher blood glucose is the normal response to not enough glucose in cells.
Cells get glucose not from “blood” (which is confined to the vasculature) but from the extravascular fluid which passes by each cell. That fluid flows much more slowly than blood, and is much harder to measure.
Blood glucose goes down because the cells that are the ultimate target for that glucose are getting enough. Lowering blood glucose by methods that don’t deliver glucose to cells the way that insulin does won’t have the same effects as delivering glucose to cells.
The ultimate problem is that not all cells have the same level of glucose delivery. Cells are different distances from capillaries, so the extravascular fluid getting to some of them has less glucose and less insulin because the intervening cells have consumed it. That is the physiological reason for hyperglycemia, to get more glucose to cells too far from a capillary, and also for insulin resistance, to get more insulin resistance to cells too far from a capillary too.

Crystal Holmes, DPM

As a podiatrist practicing at the University of Michigan Medical School’s Division of Metabolism, Endocrinology and Diabetes, I think it is important not to paint podiatrists with a collective broad brush based on one individual podiatrist’s prospective and practice choice. Not all podiatrists choose to incorporate alternative medicine into their practices, just as the same is true for their allopathic and osteopathic counterparts. As you know, podiatrists play an integral role in the management of diabetes and the reduction of amputation risk. In fact, according to the American Diabetes Association, studies have shown that a comprehensive foot care treatment plan can reduce amputation rates by as much as 85 percent. To your point, prevention of diabetes’ sometimes deadly and often devastating consequences, such as amputation, is a shared goal. I consider myself on the front lines of diabetes care every day. Podiatrist are medically and surgically trained to treat foot conditions that result from the disease, such as neuropathy, infection, diabetic ulcers and amputations. We relish our responsibility as collaborative members of a diabetes management team. To egregiously assert “there is a reason why podiatrists are only licensed to practice below the leg” is unnecessary and implies a lack of knowledge about systemic disease processes. We are specialists uniquely qualified among medical professionals to treat the foot and ankle based on our education, training and experience.

Nathan Myers

On one hand: “Are outcomes just as good for those whose diabetes is controlled by medication alone as for those who [also] include dietary and exercise adjustments?” … “I’ll have to look at that more closely”
On the other: “It is inconceivable that anyone who considers themselves a ‘real’ health care provider would not address things like diet and exercise.”
Well, which is it? Should we conclude that PalMD cannot conceivably consider himself a “real” health care provider (whatever “real” means)? Or is daed wrong?
And, do pesticide residues really not count as toxins? I thought toxicity was their entire purpose. I gather that a few of them have been demonstrated non-toxic to test mammals, but not most.

Chris

I’m sorry, I missed the part of pesticides and diabetes. Where was that mentioned? Is there some pesticide that you are talking about?
As I recall the dose makes the toxin. I spray a mixture of soap and baking soda on my roses. Safe for us, toxic for aphids, and helps reduce fungus.
One pesticide that I believe can be related to diabetes is tobacco. Tobacco juice is used as a homemade pesticide (it is very nasty, I’ve never used it). Many many many years ago I worked in the same office area was in danger of losing his leg because of his diabetes and his smoking habit. He lamented his fate to me, and I told him really needed to work hard to quit.

PalMD

Thank you, Crystal.
I thought I made clear (aside from my perhaps unnecessary snark) that i recommend all my diabetics follow up with a good podiatrist (and we have a number of good ones around here). The snarky snap was more in reference to Kornfeld’s apparent assumption that because he is a foot and ankle expert, he is also an expert in internal medicine.
I am no podiatrist, and he is no internist.

MS3

As a medical student I could add that current medical education heavily stresses lifestyle intervention for diabetics. In response to Shannon the way I was taught that if the blood glucose is well controlled then that patient effectively no longer has diabetes usually independent of how they got there. Blood glucose can be controlled by carefully counting calories/balanced meals, using medications to supplement insulin, and exercise with insulin-independent glucose uptake by active muscles. We are trained to try to get patients to do at-least two out of the three. So yes, a well-controlled and thought out diet with an exercise regime may qualify for a proportion of type 2 diabetics.

Nathan Myers

Chris: You may use your browser search function to locate the word ‘”toxins”‘ on the page (scare quotes included). I don’t know the difference between toxins and “toxins”, or between real and “real”. Maybe daed can explain.

the bug guy

MS3: My understanding is that diabetes doesn’t go away, but that it is controlled. By your definition, I no longer have diabetes. I disagree. I monitor my blood glucose daily, follow a careful diet, stay active, have my A1C tested every six months and my eyes examined every six months. I don’t specifically see a podiatrist, but I see my PCP every six months following my A1C. My diabetes is controlled, but it has not gone away.
Nathan: As for pesticide residues on food, the poison is in the dose and in the US overall they are very low. You can get details from the USDA Pesticide Data Program.
I have the reference at work, but something like 99.99% of the pesticides you ingest are naturally occuring protective chemicals in the plants we eat. Using the Ames test, many are considered carcinogenic and are also acutely poisonous at even fairly low doses.

“Toxins” (in the sense that I was using the term (which is non-standard (at least for this blog) which is why I put it in quotes)) are mythic substances that taint all things derived from things modern, things scientific, things rational, things changed from their natural state.
Natural spring water has no “toxins” in it, even if it is contaminated with bacteria. Ultra pure water that has been purified by modern techniques is full of “toxins”. Raw, unpasteurized milk has no “toxins”, even if it does have TB and other disease bacteria. Pasteurized milk is loaded with “toxins”, even if all known tests show it to be safe and wholesome.
Unprocessed cane juice has no “toxins”. During the processing, as impurities are removed, “toxins” are generated. The greater the degree of purification, the greater the “toxin” load. Pure, white, cane sugar has a very high level of “toxins”.
Once “toxins” are made, they are impossible to destroy. In some ways they have homeopathic properties in that no amount of dilution makes them safe. Similarly, “toxins” cannot be measured or quantified by any scientific test.
The purification processes that most pharmaceutical ingredients go through, loads them up with high levels of “toxins”. If a substance has been purified to such an extent that it can be called by its scientific name, Sodium Chloride, for example, it has been made “toxic”.

Chris

I see Nathan is just trying to hijack this thread for his own prejudices. I know perfectly well what a toxin it, much more than Nathan. Water is a also a toxin if enough is consumed.
I still see no relationship between pesticides and diabetes.

Sharon Astyk

The reason I asked is that my cousin, who was diagnosed last year with Type 1 diabetes was, in his training, discouraged (or he felt he was discouraged) from making dietary changes. He’s already an athlete, and while being trained to manage his condition, asked a number of questions about dietary changes he might make. He’s 20 years old, and what he was told was that people his age were unlikely to make meaningful dietary shifts, so he simply shouldn’t worry about it. He was a little puzzled by this and recounted it to family – wondering why, when he expressed an interest, he was given no encouragement. I’m not sure if this is typical or not, but while I realize that type 1 and 2 diabetes are different in many ways, I simply wondered if this lack of attention to diet has emerged because of compelling research that suggests that outcomes are similar whether or not there are dietary changes. Thank you for the responses!
Sharon

PalMD

Type I is a very different disease. The progress of the disease in type II can be strongly affected by diet and exercise. In Type I, since there is no significant insulin resistance and the other metabolic problems of type II, diet is most significant in monitoring blood sugars from moment to moment, and insulin can be administered based on what you eat. While a high-junk diet isn’t good, it’s probably worse for a type II.

Rogue Epidemiologist

@JP
And some people enbrace their diagnoses (this issue came up in a discussion of autism a while ago).
With that said, there is a validity in applying such terminology from the standpoint of research, where you’re not dealing with the person on an individual level, but rather as a member of a group under study. For example, if you are studying the spread of syphilis in gay men, generally, you are studying men who have sex with men (MSM) and refer to them as such. There is an identity issue at play — not all MSM identify as “gay.” But they are having sex with men, so you label them for what they do.
Likewise a glucoutilization-impaired patient may not want to be called a diabetic. But if we’re talking about and studying particular health conditions, if you have diabetes, then as a subject in a study you will be called a diabetic. Walks like a duck, talks like a duck, and so forth.

JP

@Rogue Epidemiologist
I tried to be specific in directing my message to health care providers and only suggest awareness. In research, if you do study people with diabetes and decide to share it via a publication in one of the American Diabetes Association journals (Diabetes, Diabetes Care) or the EASD journal Diabetologia you will not refer to participants as diabetics.

Chris

JP

@Chris:
There have been a few studies examining the association between POPs and diabetes or insulin resistance. I thought that it might be of interest to you since you said “I still see no relationship between pesticides and diabetes.” in a previous post. I don’t study this area myself so I have no data to share. I thought that PubMed would be the easiest tool for you to see what had been published recently.

JP

Sharon’s question at comment 6 also reminded me of trials showing a persisting improvement in glycemic control in response to a short period (around 3 weeks I think) of insulin therapy in people with newly diagnosed type 2 diabetes. More recently, Retnakaran showed this might also be true in insulin naive patients with established type 2 diabetes (in volume 12 of Diabetes, Obesity, and Metabolism, Jan 2010).

Nathan Myers

(How clairvoyant of you, Chris, to divine my intentions. Maybe you have missed your calling.) In fact, I also know of no connection between “toxins” and diabetes, though I am now certain that daed knows even less.
But the first question in #11 remains unanswered. Is any responsible physician obliged to include dietary analysis and advice in diabetic treatment? PalMD appears to say not, which astounds me. Surely, PalMD, habitually wide blood-sugar excursions countered with large insulin injections results in poorer outcomes, over time, than the more gradual changes and correspondingly smaller corrections that can be arranged through careful diet? I don’t pretend to know, I’m asking.
On the topic of pesticides (which I did not intend to introduce, but remain curious about), there is apparently rather more to consider than dosage. Those pesticides that mimic vertebrate sex hormones have, I understand, a distinctly non-monotonic response curve, such that test subjects exposed to high dosages in labs may respond much less strongly than to the comparatively low dosages found in their environment. This is taken to explain sexual development anomalies in fish and amphibians, and, possibly, various human cancers. We may be inclined to doubt similar effects in the insulin response system, but has anybody checked? Is the incidence of type I or II diabetes increasing, consistent with an environmental contribution?

JP

@28 Nathan Myers:
Are you assuming that advice from a physician to modify dietary intake and physical activity has an impact on these behaviors? Physician advice has not been clearly shown to be effective. As a result, I think that it might be more appropriate to focus on medication with referrals to appropriate diabetes educators (if available) than focusing too much effort on diet and physical activity modification.
A second question, how would you determine that an increase in the incidence of type 1 or type 2 diabetes was consistent with an environmental contribution (here assuming that by environment you mean chemical exposures)?

Chris

Chris

I should also say that I also dislike those who make a claim and then when data is asked for pull the “Google that” or “PubMed” that. If you have evidence you would actually present it.
Nathan, you are being very off topic, and not exactly providing supporting evidence. You are attributing a side affect that may be present in a set of pesticides, but that does not mean it holds for all pesticides. As I said, there are lots of different pesticides and and you must be precise about the one you are discussing.

PalMD

JP

Chris and PalMD:
Fair point about the use of undefined abbreviations. I apologize for not providing a definition. POPs are Persistent Organochlorine Pollutants. My understanding is that one source of POPs are certain pesticides. It has been something of a hot topic in type 2 diabetes research over the last few years. My suggestion about doing a PubMed search was intended to provide you with more information than I had the time or ability to provide about a potential relationship between pesticides and diabetes.

Nathan Myers

Chris: Teasing out the cause of a change in incidence of an illness requires application of Science. Epidemics indicate pathogens. Others match spread of populations, as in sickle-cell anemia following African migrations. Environmental causes or triggers would exhibit different patterns. I assume this is all elementary among research pathologists.
I don’t offer evidence because I posted to ask the question. If I knew, I wouldn’t have to ask. I’m sorry you feel it’s off topic, but it seems to me it’s up to PalMD to make such pronouncements.
JP: I am assuming that some fraction of people with a life-threatening illness would pay attention to the advice of someone they are paying for advice. Certainly some wouldn’t, but it’s not like nicotine. (Once I discovered onions were causing my bleeding sinuses, I dropped them like that, despite the difficulty.) I can’t help feeling that people who won’t change their diet to save their own lives have made their choice; maybe that attitude would make me a poor physician. Anyway, if I presented with diabetes I would consider it a mark of incompetence not to hear anything about diet.

the bug guy

A quick correction, POPs are Persistent Organic Pollutants, as per the Stockholm Convention.
For the most part, organochlorine (OC) pesticides have been seriously restricted or removed from use worldwide, with specific exemptions like DDT as an interior repellent spray against Anopheles mosquitoes that vector malaria when other materials are not economically available. If you examine the USDA data I linked earlier, you will see that most of the OC resides present on food are the result of their persistence in soil and not from current agricultural practices.
There is still a lot of work to do with the information that some materials can have an effect at lower concentrations, but that hasn’t stopped some from trying to extrapolate what is most likely present in only a few materials to broad classes of chemicals like pesticides.

JP

@35 Nathan Myers:
I think that I had a different understanding of your comment. I think that there is sufficient evidence to support that a physician should inform patient with type 2 diabetes of the impact of diet and physical activity on glycemic control. I do not think there is clear evidence to suggest that a physician recommendation alone is sufficient to modify dietary intake and physical activity.
@36 the bug guy:
Thanks for the clarification, I attended a lecture on investigations into POPs and type 2 diabetes about a year ago. I don’t recall a lot of the lecture unfortunately. I do remember that the investigators were examining the association between POP exposure in areas with a fairly long history agricultural uses.

JP

@28 Nathan Myers:
You asked:
“habitually wide blood-sugar excursions countered with large insulin injections results in poorer outcomes, over time, than the more gradual changes and correspondingly smaller corrections that can be arranged through careful diet? I don’t pretend to know, I’m asking.”
I am not sure why the medication treatment should be limited to insulin injections only unless you are referring to type 1 diabetes. It is likely possible for certain people with type 2 diabetes to maintain blood glucose at near normal levels through dietary intake and physical activity behaviors. I am a bit unclear on what medication only means. Medication always interacts with lifestyle behaviors. I also think that it is possible to maintain blood glucose within near normal levels using a combination of medicines depending on the defects in glucose regulation but it depends on a lot of factors including habitual lifestyle behaviors.

Vicki

This discussion seems to be assuming that a person who is newly diagnosed with diabetes is not eating an appropriate diet or getting enough physical activity. While that is certainly true in some cases, I doubt it’s true in all.
Can we step back and say that the first step might be to say something like “we know certain foods and exercise are useful for people with diabetes. What kind of exercise are you getting now?” If a patient who jogs regularly gets the “you need to exercise, being sedentary is bad for you” speech from a doctor who seems unwilling to hear that they already do exercise, it’s not going to help. In fact, the patient may assume that the dietary advice, if any, is equally irrelevant. It’s easy to look at an “overweight” patient and assume s/he doesn’t exercise, rather than considering that maybe s/he does exercise, but is on medication that causes weight gain, or has a high set point for other reasons (such as a past history of yo-yo dieting).

JP

@Vicki:
I agree with you that understanding where a patient is starting with regard to dietary intake and physical activity is important to provide optimal treatment. I do think that it is relevant to consider that someone newly diagnosed with type 2 diabetes might be regularly physically active and consume a diet appropriate for someone without type 2 diabetes but some additional modification might better help regulate her or his blood glucose. I also want to be clear that I am not trying to imply any type of negative judgment about the character or value of someone in this situation. Blaming the patient for developing type 2 diabetes is often not productive and in many cases might ignore the strong influences of factors well outside of the patient’s control (intrauterine glucose exposure is one example).

the bug guy

My PCP sent me to a diabetes center so that multiple aspects could be examined to help determine a strategy to control the diabetes. Diet, activity, medications and such were taken into account.
My type of intervention doesn’t work with everyone and so they will need medications. It doesn’t mean that they are a failure, it means that their situation is different and required a different intervention.